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OHSU Dept of Neurology Migraine As a Chronic Neurovascular Disorder

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OHSU Dept of Neurology Migraine As a Chronic Neurovascular Disorder OHSU Dept of Neurology Migraine as a Chronic Neurovascular Disorder Tarvez Tucker, M.D. Associate Professor of Neurology and Neurocritical Care April 5, 2013 ??? Headache “Triggers”??? . MSG . Zucchini . Dijon mustard . Provolone cheese . Peanut butter . Chocolate . Pizza NW PADRECC - Parkinson's Disease Research, Education & Clinical Center Portland VA Medical Center www.parkinsons.va.gov/northwest 1 Warmed Goat Cheese Salad with Grilled Vegetables . Free of: calories 184 . Caffeine protein 10 grams . Chocolate fat 8 grams . Citrus fruits carbohydrates 18 gm . Red wine . Aged cheese . MSG and nitrates . Aspartame . Nuts . Onions and garlic 2 April 5, 2013 Migaine Prodromes??? . Mood swings . Urge to clean out closets . Yawning . Craving the new dark M&Ms . Talkativeness . Stomach discomfort . Craving for sex Recognition of Ominous Headache . “First or worst” headache of my life . New-onset headache in mid-life or older . Change in character of longstanding headache . Strictly unilateral headache . Headache associated with fever, meningeal signs, cancer or immunosuppression . Headache associated with abnormal neurological examination 3 Primary Headache Classification . Migraine without aura (common) . Migraine with aura (classic) . Tension-type headache . Cluster headache 4 Ap ril 5, 2013 Criteria for office diagnosis of episodic tension-type headache A. Headache pain accompained by two of the following symptoms: • Pressing/tightening (nonpulsating) quality • Bilateral location • Not aggravated by routine physical activity B. Headache pain accompanied by both of the following symptoms: • No nausea or vomiting • Photophobia and phonophobia absent or only one present . C. Fewer than 15 days per month with D. No evidence of organic disease IHS diagnostic criteria for migraine without aura A. Lasting 4 to 72 hours B. Two of the following: • Unilateral headache pain location • Pulsating quality • Moderate or severe intensity • Aggravation by routine physical activity C. At least one of the following: • Nausea and/or vomiting • Photophobia and phonophobia D. At least five attacks fulfilling A, B, and C E. No evidence of organic disease NW P ADRECC - Parkinson 's Dis eas e Res earch, Education & C linical Center Portland VA Medical C ent er www .pa rkinsons .va .gov/nort hwest 5 April 5, 2013 Common Symptoms of Migraine ■ Headache ■ Visual or sensory aura ■ Anorexia, nausea, vomiting, diarrhea ■ Photophobia, phonophobia ■ Mood changes NW PADRECC - Parkinson's Disease Research, Education & Clinical Center Portland VA Medical Center www.parkinsons.va.gov/northwest 6 April 5, 2013 Criteria for office diagnosis of migrai ne w ith au ra A. Headache pain is preceded by at least one of the following neurologic symptoms: • Visual – Scintillating scotoma – Fortification spectra – Photopsia • Sensory – Paresthesia – Numbness – Unilateral weakness – Speech disturbance (aphasia) B. No evidence of organic disease NW PADRECC - Parkinson's Disease Research, Education & Clinical Center Portland VA Medical Center www.parkinsons.va.gov/northwest 7 8 9 10 Migraine in Clinical Practice ■ There are 28 million migraine sufferers in the US ■ Only half are diagnosed ■ Far fewer are receiving optimal care ■ Clinicians interact with migraine patients ■ As primary consultations ■ Amidst other co-morbid medical conditions ■ Often migraine goes unrecognized Lipton RB, Diamond S, Reed ML, et al. Migraine diagnosis and treatment: American Migraine Study II. Headache. 2001;41:538-645. Juanita – 27 yo Female with 2-3 HAs per Month 11 Clinical Assessment ■ How many headache diagnoses does she have? . One? . Two? . Three? . More? Clinical Assessment ■ How many different headache treatments should this patient have? . One? . Two? . Three? . More? 12 NW PADRECC - Parkinson's Disease Research, Education & Clinical Center Portland VA Medical Center www.parkinsons.va.gov/northwest Pathophysiology of Migraine Evolution of the Vascular Theory The Neurovascular Theory 13 Trigeminal Nucleus Caudalis Extends to Dorsal Horn for C2, C3, and C4, Resulting in Neck and Posterior Head Pain Cranial Parasympathetic Stimulation Can Result in “Sinus Symptoms” Which Often Leads to a Diagnosis of Sinus Headache 14 April 5, 2013 Common Clinical Presentations of Migraine Migraine Sinus Tension “ID Migraine Screener” ■ Do you feel nauseated or sick to your stomach with your headache? ■ Does light bother you? ■ Do your headaches limit your ability to work, study or do what you need to do for at least a day? Lipton et al, Neurology August 2003 15 Nausea ■ Average Office Visit: 11-15 minutes ■ Optimal single and three-variable models for the diagnosis of migraine ■ Only single-variable model: nausea ■ Best three-variable model: nausea/photophobia/pulsating pain ■ Best + likelihood ratios/ least – likelihood ratios - Martin, V et al Headache 2005 Brenda – 29 yo Mother on Vacation 16 Symptomatic and Abortive Therapy for Migraine ■ Analgesics/ Antiemetics ■ NSAIDS ■ Opiates ■ Ergotamine/dihydroerotamine ■ Isometheptene mucate ■ Serotonin (5-HT) (triptans) receptor agonists Symptomatic and Abortive Therapy for Migraine . Analgesic combinations . Beware of overuse and “rebound” . Use of medications more than 15 days/month . Caffeine-combinations the culprit . Watch for acetominophen toxicity (3-4 grams per day) . Excedrin, Fioricet, Lortab,Percocet, Ultracet 17 When to Prevent Migraine . Interference with work/school . Acute meds fail or are contraindicated . Medication overuse . Adverse side effects . Complicated migraine . (hemiplegic, basilar) Colleen – 27 yo Teacher and Single Mother 18 Terry – 45 yo Female with Daily Headache Preventative Therapy . FDA-Approved Medications . Propranolol, Timolol . Methysergide (unavailable) . Valproic Acid . Topiramate (2004) . NSAIDS (Cox-2/long-acting) . Tricyclic Antidepressants . Calcium Channel Blockers . Anti-convulsants 19 PREVENTION of Headache . Keep a headache diary . Food triggers, sleep schedule, stress . Consider dietary supplement . Vitamin B2 (400 mg) and Magnesium (400 mg) . Preventative Medicines . Beta blockers, Calcium channel blockers, Anti- convulsants (Topamax,Neurontin) . BCP without placebo (Seasonale) . Reduce stress/barometric change . Move to Arizona . Change your boss/spouse/med school dean Botulinum Toxin . Several open-label and small placebo-controlled trials . Recent abstract Neurology 64: March 2005 . 355 patients with CDH (>15/mo) . Botox Type A/placebo every 90 days/9 mo . HA-free days: no significance . HA frequency reduction by >50% at day 180: p=0.027 20 Preventive Therapy: Maxiums . “Start low and go slow” . 10 mg amitriptyline or nortriptyline . 80-120 mg verapamil (SR) . 40-80 mg propranolol . 500 mg valproic acid (ER)/topiramate 25 mg . Cox 2 inhibitors . Hang on for 4-6 weeks/ Diary!! Migraine as an Episodic Disorder vs. Migraine as a Disease 21 Migraine as a Risk Factor for Subclinical Brain Lesions . The risk of deep white matter lesions on MRI brain scans is increased in patients with migraine with and without aura . And the risk is further increased with attack frequency greater than one per month. - JAMA January 28, 2004 22 NWApril PADRECC 5, 2013 - Parkinson's Disease Research, Education & Clinical Center Portland VA Medical Center www.parkinsons.va.gov/northwest Reducing the Risk of Migraine Transformation to Chronic Daily Headache Disease modification . Early diagnosis . Early behavioral change . Early prophylactic phamacotherapy . Only ½ of patients candidate for prevention receive it . Analysis of pooled data from 3 topiramate trials: reduced the risk of development of chronic forms of headache Limmroth, V. Headache 2007 23 Weight and Migraine Possible Mechanisms . CGRP levels increased in obese women . CGRP: postsynaptic mediator of trigeminovascular inflammation . Obesity is pro-inflammatory . High levels of IL-6 and TNF-a . Migraine . Neurovascular inflammation . Like obesity, comorbid with cardiovascular disorders, and risk of stroke (with aura) Weight and Migraine . 12% of adults have migraine. 64% of US adults are overweight or obese (BMI 25-35) . Overweight and obese individuals have increased frequency, not prevalence, of migraine . Significant associations: disability, photo- and phono- phobia . Obesity is comorbid with CDH, fibromyalgia and chronic back pain 24 DEVOLUTION!!! Percutaneous closure of patent foramen ovale reduces the frequency of migraine attacks . Paradoxical emboli through right to left shunt…….stroke, ?migraine . Prevalence of PFO and ischemic lesions in migraine cf to healthy controls . 215 patients: 22% with migraine (cf 12%) . Post closure HA freq decreased by 54% . Neurology 2004;62:1399-1401 M. Schwerzmann et al, University Hospitals Bern, Switzerland 25 26 ? Hypotheses? . Transcranial Doppler sonography detects >10 microembolic signals/hr in PFO pts . Arise from thrombi of venous circulation . Normally lysed in the pulmonary circulation . Valsalva: microemboli reach brain Central Sensitivity Syndromes . Irritable Bowel . Overactive Bladder . Low Back Pain, TMJ Disorder . Migraine and Chronic Tension Headaches . Comorbid: mood disturbance . Associated: Chronic Fatigue, Sleep Disturbance, “Fibro-Fog,” Endocrine Dysfunction 27 Central Sensitization . Nociception plus . Modulation in the CNS . Emotional and affective components . Temporal summation (“wind up”) . Second pain (C fibers stim > q 3 sec); inh by NMDA rec antagonists . Pain amplification syndromes . Heightened sensitivity to non-painful stimuli as well: touch, heat, cold, light, sound, smell . HPA, high levels of
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